Healthcare Provider Details

I. General information

NPI: 1962472407
Provider Name (Legal Business Name): DOUGLAS T JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BARGEN ST F 102
NEWARK NJ
07103
US

IV. Provider business mailing address

PO BOX 18925
NEWARK NJ
07191
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-3555
  • Fax: 973-972-3510
Mailing address:
  • Phone: 973-972-3555
  • Fax: 973-972-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number25MA06601400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: